Immediate Breast Reconstruction in Skin-Reducing Mastectomy with Prepectoral Polyuretane (Pu) Implant Covered with an Autologous Dermo-Adipose Flap.

BACKGROUND: The aim of this study was to present our new technique of immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, in skin-reducing mastectomy both for risk-reducing (prophylactic mastectomy) and therapeutic cases. METHODS: We performed a single-center, retrospective review of 21 patients (mean age 47 years), undergone skin-reducing mastectomy and immediate breast reconstruction with prepectoral Polyuretane (PU) Implants, covered with an autologous dermo-adipose flap, un the period January 2018-June 2021. All procedures were performed by the same surgeon. RESULTS: A total of 36 skin-reducing mastectomies (6 curative, 15 prophylactic) with one-stage prepectoral PU foam-coated implant and autologous dermo-adipose flap reconstruction were performed. All postoperative complications were collected. Quality of life (QoL) and satisfaction with reconstruction were evaluated through the BREAST-Q questionnaire, administered preoperatively and at 12 months after surgery. Independent Student's t tests were used to compare means of continuous variables and Chi-square test was used for ordinal variables. A p-value ≤0.05 was considered statistically significant. Uni- and multiple linear regression analyses were used to confirm all results. Out of 21 patients, we observed one small wound dehiscence and one partial Nipple-Areola Complex (NAC) necrosis. All cases of minor complications were managed conservatively and did not affect the quality of the final outcome. No implant loss was observed. No significant severe capsular contracture (grade III or IV) was detected at follow-up. Overall satisfaction with breasts, psychosocial, physical and sexual well-being all significantly increased, analyzing BRAST-Q data. Statistical analysis showed a significant influence of diabetes on the risk of complications. CONCLUSIONS: Our experience suggests that the procedure described is effective, feasible and cost-effective. It is easier to perform compared to similar and more demanding procedure, reduces operative time, and minimizes complications related to manipulation of the pectoralis major muscle, while also contributing to the containment of costs. Moreover, it appears to be oncologically safe, provides good esthetic results with low postoperative complication rate and leads to high level of patients' satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Primary Leiomyosarcoma of the Great Saphenous Vein: Case Report and Review of the Literature.

Soft tissue sarcomas are very rare tumors, representing less than 1% of all cancers. Leiomyosarcomas are a rare group of them representing about 6% of soft tissue sarcomas and they involve smooth muscles. Less than 2% of all leiomyosarcomas involves large blood vessels. Leiomyosarcomas of vein tunica media are very rare (1/100,000 malignant cancers) and only 10% of these originate from the great saphenous vein. In this article, we report a clinical case that occurred in our institution and review all the literature available at now.

A combined protocol for improving reconstruction of scrotal skin avulsions: The experience of the University Hospital Center of Foggia.

OBJECTIVE: Scrotal degloving injuries are rare and constitute a challenge for reconstructive surgeons. The authors describe their successful experience with a combined reconstruction protocol using an acellular dermal matrix (ADM), negative pressure wound therapy (NPWT) and a split-thickness skin graft (STSG), and the retrospective assessment of overall morbidity and esthetic outcomes. METHODS: Five consecutive patients underwent a wide excision of necrotic scrotal skin and a reconstruction procedure using a combined protocol with NPWT, Pelnac®, and STSG. The efficacy of this treatment was determined by assessing overall morbidity and esthetic outcomes with the Vancouver Scar Scale (VSS). RESULTS: The combined protocol made it possible to create an environment that promoted wound healing, improved graft intake, and gage the reconstructed site a more natural look. No significant problems were observed. Satisfactory cosmetic and functional results were obtained in all patients as shown by VSS scores obtained. CONCLUSIONS: We believe that this combined protocol is a reliable alternative to flaps and should be considered an excellent option in scrotal reconstruction, especially in critical patients.

The objective evaluation of triamcinolone acetonide efficacy in keloids management using Antera3D® imaging system.

Background: Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. These lesions do not spontaneously regress and can cause cosmetic disfigurements and functional disabilities. IntraLesional Injection of Triamcinolone Acetonide (ILITA), alone or in combination with other therapy, is one of the first-line treatment modalities. In this study the authors evaluated the objective efficacy of ILITA treatment in keloids management using this new imaging system. Materials and Methods: 37 patients with 45 keloid scars were treated with intralesional injection of triamcinolone acetonide (TAC) 20 mg/ml at an interval of three weeks. Antera3D® camera took the images and dates of the treated area in each patient, before the treatment (T0) and at three weeks after the last injection (T1). The system processed the levels of color, elevations, melanin and hemoglobin expression. All the scars were also evaluated, at the same times, by validated Vancouver Scar Scale (VSS). Comparison of the variables was performed using a Wilcoxon signed-rank test with a p < 0.05. Results: At T0, mean VSS score was 8.67 ± 1.35 which reduced to 3.62 ± 1.72 at final follow up. Antera3D® scores were statistically significant differences in color (8.14 ± 2.41 vs 9.54 ± 1.81), protrusion (381.3 ± 15.6 vs 198.6 ± 21.3), melanin (0.53 ± 0.02 vs 0.62 ± 0.2) and hemoglobin (1.26 ± 0.41 vs 2.21 ± 0.41) expression levels after the treatment. Conclusions: In our clinical trial, the data results demonstrated that ILITA seems to be effective in reducing keloid dimensions and symptoms such as itching and pain, even if the treatment has local minimal adverse effects such as pain, telangiectasias and atrophy. Lay Summary: Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. Large keloids can cause cosmetic disfigurements and functional disabilities that affect quality of life. In literature, several treatment approaches have been described but, to date, no single method is considered superior. The International Advisory Panel on Scar Management recommended the use of intralesional steroid injections for keloids treatment. The efficacy of treatment may be evaluated with subjective scale; as no one can guarantee an objective evaluation. To eliminate the observer and/or patient factors, and to obtain a reliable, consistent, feasible, valid and objective evaluation a skin analysis camera system called Antera3D® (Miravex, Dublin, Ireland) can be used.In this study the authors evaluated the objective efficacy of triamcinolone acetonide treatment in keloids management using this imaging system. In this series, for Antera3D® scores there were statistically significant differences in color, protrusion, melanin and hemoglobin expression levels before and after treatment. The device directly shows the treatment changes, measured objectively and accurately, without bias of traditional evaluation scoring scale.Antera3D® system guarantees an objective evaluation of effectiveness of scar treatment enabling clinicians to modulate the therapy according to the scores registered.

Role of a new acellular dermal matrix in a multistep combined treatment of dermatofibrosarcoma protuberans of the lumbar region: a case report.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare skin fibroblastic tumor, with a high rate of recurrence. The treatment of DFSP is generally surgical, and wide local excision is the mainstay of surgical treatment. Therefore, complete assessment of all surgical margins is fundamental before definitive reconstruction. The reconstruction is a challenge for plastic surgeons, especially in particular anatomical areas (for aesthetic or functional problems) or in patients who are not candidates for more complex surgical treatments. We describe an alternative approach for reconstructive treatment of the lumbar area after wide excision of DFSP (without fresh-frozen sections) in a young obese woman with a history of smoking, using a new type of acellular dermal matrix (ADM) in a combined management protocol. The benefits of ADM are numerous: immediate wound closure and prevention of infections and excessive drying; minimal donor site morbidity; and good functional and aesthetic outcomes. Moreover, it is a temporary cover while the anatomical specimen is histologically analyzed, without donor site morbidity or prevention of any future surgery (if the margins are not tumor-free) or radiotherapy. CASE PRESENTATION: In October 2019, a 34-year old obese Caucasian Woman with a history of smoking came to our institute for a multinodular growing polypoid mass in her lumbar region. An incisional biopsy diagnosed DFSP. The patient underwent proper staging. A wide local excision with 3 cm clinically healthy tissue margins down to the muscle fascia was performed and the defect was repaired using a combined approach with a new artificial bilaminar dermal template (Pelnac®, Gunze Ltd., Osaka, Japan) and a negative-pressure wound therapy system (V.A.C.®, KCI, San Antonio, USA). After the final histological examination revealed tumor-free margins, a split-thickness graft was harvested from the right gluteus and fixed to the new derma with negative-pressure wound therapy. Postoperative radiotherapy was not necessary. After 15 days, the wound had healed without complications, with satisfactory aesthetic outcome and with no limitation of back motion or pain. After 6 months of follow-up, the patient was free from disease. CONCLUSIONS: This is the first reported case of Pelnac® use in DFSP reconstruction of the lumbar region. We believe that the multistep approach described herein may be a good alternative approach in selected patients with wide resections in particular anatomical areas, especially when frozen sections (with Mohs micrographic surgery) are not available.

Reduction of seroma and improvement of quality of life after early drain removal in immediate breast reconstruction with tissue expander. Preliminary report from a randomized controlled study.

Seroma is the most common complication of breast reconstruction with tissue expander (incidence 0.2-20%) with increased risk of infection and implant loss by 4-6 fold. About 90% of plastic surgeons routinely placed drains for its prevention. We theorized that early drain removal is a safe procedure that improves postoperative quality of life (QoL), reducing pain, length of hospital stay, and limitations on daily activities. We divided 49 patients operated on between September 2016 and March 2018 (follow-up: 9-26 months) into two groups: Group1 (output-based; drains removed when <30 ml/day); and Group2 (early-removal; at 3-4 days postop.). A study-specific questionnaire about the patient's QoL was conducted 3 weeks after surgery. We performed an intention-to-treat analysis. A comparison was performed using a Fisher test and a Mann-Whitney U test with p = 0.05. We observed lower production of wound fluid (641±49 ml vs 231±20 ml; p = 0.004), and a shorter time until wound healing (31.3±4.2 days vs 22±3.9 days; p = 0.031) for Group 2. The difference for infection (p = 0.36), impaired wound healing (p = 0.22), and the seroma formation period (p = 0.11) was not significant. Group 2 experienced less breast pain (8% vs 87.5%; p = 0.001), fewer limitations in daily activities (16% vs 50%; p = 0.002), in mobility (20% vs 83.3%; p = 0.001), and in social life (8% vs 91.7%; p < 0.001), and a better quality of sleep than Group 1 (36% vs 75%; p = 0.002). Group 2 did not require home care after hospital discharge (p < 0.001). The limitations of study are: its small sample size, the wound healing assessment, and the use of a non-validated questionnaire.

Release of pseudosyndactyly in recessive dystrophic epidermolysis bullosa using a dermal regeneration template glove: the Foggia experience.

BACKGROUND: Epidermolysis bullosa (EB) comprises a heterogeneous group of rare genetic diseases associated with skin blistering caused by minimal trauma. A major and common EB subtype, recessive dystrophic EB (RDEB), is characterized by altered wound healing, inflammatory dysbalance and fibrotic changes associated with reduced to absent collagen VII. Because of its exposed position and its continued use in daily activities, the hand is constantly at risk of microtrauma and is therefore one of the organs most affected by the disease with highly disabling deformities that represent a challenging field in hand surgery practice. METHODS: The authors present their experience in the microsurgical treatment of pseudosyndactylies comparing the classic dressing with vaseline gauze with an innovative "glove protocol" using Integra® dermal regeneration template. The endpoints analyzed were: healing times, hospital stay time, discomfort for the patient, free-recurrence interval, follow-up range and major complications. RESULTS: A total of 34 procedures were performed on 24 RDEB patients with hand deformities. Compared with the dressing with vaseline gauze, microsurgery followed by application of dermal regeneration template gloves allowed a significant reduction of hospital stay, healing time, and dressing pain as well as an increased recurrence-free interval. CONCLUSIONS: The microsurgical approach followed by our new protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.

Cling Wrap Technique: An Inexpensive and Simple Way to Seal Negative Pressure Wound Therapy on External Fixation Devices.

SUMMARY: Negative pressure therapy is often applied to treat limb traumas with or without bone exposure. However, sealing a negative pressure dressing in the presence of an external fixation device may be complicated and time consuming. In this technique, we attempted to maintain vacuum conditions by preventing air leakage around the screws using plastic drape and cling wrap as the final layer over the external fixation device. To prevent rupturing of the wrap, the prominences of the pins and rods were covered using cotton wool roll. This novel solution is also effective for complex and extended wounds, with no need for additional dressing changes and no occurrence of complications for approximately 4 days. Furthermore, it is an inexpensive, quick, and readily available technique requiring minimal training to perform. It is also adaptable to any anatomical region, allowing the inspection of the limb when required.

Adipose Stem Cells and Platelet-Rich Plasma Induce Vascular-Like Structures in a Dermal Regeneration Template.

In the context of biointeractive dressings used for enhancing wound healing, the use of stromal vascular fraction (SVF) or adipose-derived stem cells (ASCs) hereof derived has not been fully exploited yet. Noncultured SVF, a heterogeneous mesenchymal population of cells, is attractive in the field of dermal regeneration because it can be instantaneously obtained, avoids genomic alterations, and is comparatively safer than cultured ASCs. Integra® Dermal Regeneration Template (DRT) was sprinkled with ASCs in complete medium supplemented with 10% fetal bovine serum (FBS), or SVF, obtained from emulsified or nonemulsified fat, in medium supplemented with 2% platelet-rich plasma (PRP). The presence and differentiation of cells were evaluated by standard histochemistry and immunohistochemistry, whereas conditioned media were analyzed for vascular endothelial growth factors (VEGF) by ELISA. In vitro experiments were conducted to analyze ASC proliferation in the presence of either FBS or PRP. Deposition of ASCs in medium supplemented with FBS caused their integration into Integra DRT as early as 1 h. ASCs were found as aggregates until 6-10 days without forming organized structures. When seeded onto Integra DRT, SVF cells in medium supplemented with PRP formed aggregates at early times, which at 7 and 10 days organized into vascular-like structures, lined by CD31+ and smooth muscle actin-positive cells. With nonemulsified fat, the lacunar structures did not show an organized distribution of SVF cells. PRP induced ASC proliferation although at lower level than FBS. VEGF secretion was enhanced when fat emulsification was introduced into the protocol. In conclusion, the combination of SVF cells obtained from emulsified fat, PRP, and Integra DRT exhibit synergistic effect on the formation of vessel-like structures indicating a step forward aimed at regenerative surgery for chronic wound healing.

Utility of a New Artificial Dermis as a Successful Tool in Face and Scalp Reconstruction for Skin Cancer: Analysis of the Efficacy, Safety, and Aesthetic Outcomes.

Radical ablative surgery is the gold standard treatment of head skin cancer. The authors expose their experience with a new artificial dermis (Pelnac®), analyzing retrospectively the overall morbidity and aesthetic outcomes. 16 consecutive patients underwent two surgical procedures under local anesthesia. The first involved the tumor removal and application of the ADM. In the second, the exposed tissue was covered with a split-thickness skin graft. On follow-up (6 months), tumor recurrences, quality of scars (using the Vancouver Scar Scale), and patient reported outcomes (using FACE-Q Skin Cancer Module) were evaluated. 10 were males and 6 females, with a mean age of 73 years (61-89). The follow-up ranged from 12 to 48 months (mean: 30). The sites of skin tumor were scalp (12 cases), forehead (2), cheek (1), and zygomatic area (1). Nine patients underwent previous local surgery; two received radiotherapy. The average length of hospital stay was 3.2 days. The mean surface area of the defect was 59.15 cm2 (16.9-89.5). In three cases, the surgical bed was bone without periosteum. The malignant tumors excised were basal cell carcinoma (68.75%), squamous cell carcinoma (18.75%), malignant melanoma (6.25%), and sarcoma (6.25%). The mean operating time was 41 minutes for the first operation (25-55) and 34 for the second (25-48). No significant problems were observed and 15 patients (93.75%) had 100 percent intake of graft. The mean time of healing was 39 days (32-45). At 6 months post-op, no tumor recurrence. Satisfactory cosmetic and functional results were obtained in all patients as shown by the VSS Scale and FACEQ skin cancer module mean scores. We believe that the artificial dermis is a reliable alternative to flaps and should be considered an excellent option in head reconstruction for skin cancer, especially in critical patients (old, with large and deep defects, with recurrent tumors, required radiotherapy).

The Role of Adipose-Derived Stem Cells, Dermal Regenerative Templates, and Platelet-Rich Plasma in Tissue Engineering-Based Treatments of Chronic Skin Wounds.

The continuous improvements in the field of both regenerative medicine and tissue engineering have allowed the design of new and more efficacious strategies for the treatment of chronic or hard-to-heal skin wounds, which represent heavy burden, from a medical and economic point of view. These novel approaches are based on the usage of three key methodologies: stem cells, growth factors, and biomimetic scaffolds. These days, the adipose tissue can be considered the main source of multipotent mesenchymal stem cells, especially adipose-derived stem cells (ASCs). ASCs are easily accessible from various fat depots and show an intrinsic plasticity in giving rise to cell types involved in wound healing and angiogenesis. ASCs can be found in fat grafts, historically used in the treatment of chronic wounds, and have been evaluated as such in both animal models and human trials, to exploit their capability of accelerating wound closure and inducing a correct remodeling of the newly formed fibrovascular tissue. Since survival and fitness of ASCs need to be improved, they are now employed in conjunction with advanced wound dressings, together with dermal regenerative templates and platelet-rich plasma (as a source of growth and healing factors). In this work, we provide an overview of the current knowledge on the topic, based on existing studies and on our own experience.